Healthcare Provider Details

I. General information

NPI: 1699717165
Provider Name (Legal Business Name): JERRY L. HAAG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 FRONT ST
ELMER NJ
08318-2143
US

IV. Provider business mailing address

350 FRONT ST
ELMER NJ
08318-2143
US

V. Phone/Fax

Practice location:
  • Phone: 856-358-8113
  • Fax: 856-358-1305
Mailing address:
  • Phone: 856-358-8113
  • Fax: 856-358-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA02782500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: